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Morbidity and Mortality Conference. Feb 13, 2002 Martin S. Rhee, MD. History of Present Illness. 54 year old female with ESRD presented with mental status changes Headache, neck discomfort x hours Confusion Fevers. Past Medical History. ESRD 2 ° to DM, HTN Hemodialysis

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Morbidity and Mortality Conference

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Morbidity and mortality conference l.jpg

Morbidity and Mortality Conference

Feb 13, 2002

Martin S. Rhee, MD


History of present illness l.jpg

History of Present Illness

54 year old female with ESRD presented with mental status changes

  • Headache, neck discomfort x hours

  • Confusion

  • Fevers


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Past Medical History

  • ESRD

    • 2° to DM, HTN

    • Hemodialysis

  • DM II (non-insulin dependent)

  • HTN

  • PVD

    • s/p R above knee amputation after failed R femoral popliteal bypass (7 months prior)

  • Osteomyelitis of R stump post AKA


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Medications

  • Nephrocaps 1 tab PO qd

  • Doxepin PO qid prn

  • OCP(estradiol/progestin)

    ADR

  • Cefazolin (hives)

  • Morphine sulfate (nausea)


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Social History

  • Married

  • Lived with husband

  • Clerk

  • Cig: 2 ppd for 30yrs

  • EtOH: rarely


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Physical Examination

  • 100.9 102 (BP not recorded)

  • Gen: Somnolent but arousable, oriented

  • HEENT: PERRL, EOMI, OP-dry, clear

  • Neck-Discomfort with flexion, JVP-7cm, no LAD

  • Cor: RRR, normal S1/S2, no M/R/G

  • Lung: CTA bilaterally

  • Abd: Active BS, soft, nontender, no HSM,

  • Ext: No C/C/E

  • Neuro: CN-grossly intact, Motor-5/5 in UE/LE, Sensory-intact to light touch


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Laboratory Data

13.1

128

89

55

291

19.7

157

8.6

40.5

4.8

23

PTT: 40.6 PT: 11.7 INR: 1.1

CK: 160 CKMB: 14.92(<5.0) Tn: 0.13(<1.50)

UA: Negative

No initial CXR

EKG(show)


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Admission EKG


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Initial Management

  • Fever & Mental Status Changes

    • Empiric levofloxacin given

    • Meningitis?, line infection?, pneumonia?, UTI?, infective endocarditis?, osteomyelitis?

    • Await for blood culture results

    • LP

    • Line removal if needed

  • Cardiac

    • Acute coronary syndrome

    • ASA, heparin, beta blocker

    • No thrombolytics


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HD #1-2

  • Hypotensive episode (SBP 79)

    • IV dopamine, IV dobutamine

    • IV fluid: wide open

  • No CP, but persistent ST elevation

    • IV tirofiban added

  • New Afib: rate controlled to 60’s

  • BCx growing G(+) cocci

    • Abx changed to vancomycin

  • LP not done

  • Line removed after HD


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HD # 3-4

  • Clinically improving

  • Tn < 1.50  21.8

  • Resolving EKG changes

  • Off dopamine, dobutamine, heparin, tirofiban

  • BCx: Staph aureus


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HD #5-7

  • Two episodes of R sided seizure

    • Phenytoin started

  • Slurred speech, R sided weakness

  • Head CT

    • 2.3cm hematoma on L frontal region

  • Transthoracic echo

    • Probable vegetation vs thrombus on MV

  • Transfer to DHMC CCU


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Medications on Transfer

  • ASA 81mg PO qd

  • Metoprolol 25mg PO bid

  • NTG paste

  • Vancomycin IV with HD

  • Rofecoxib

  • Fentanyl patch

  • Epogen


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Physical Examination

  • 36.5 69 120/70 20 98% on 6L

  • Gen: Ill appearing, somnolent, mildly confused

  • HEENT: PERRL, EOMI, OP-dry, clear

  • Neck: JVP-7cm, no LAD, supple

  • Cor:, RRR, no R/G, I-II/VI SEM on LSB

  • Lung: Slight bibasilar crackles

  • Abd: Soft, nontender, no HSM, active BS

  • Ext: Peripheral cyanosis, no C/E

  • Skin: No Janeway lesions/ Osler’s nodes/ splinter hemorrhage/ petechial lesions

  • Neuro: R sided weakness


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Laboratory Data

10.3

13393 53

5.723 7.1

518

11.5

111

34.4

PTT: 28 PT: 16.2 INR: 1.5

CK: <20 Tn: 2.57 (<0.03)

ABG: 7.42/39/214 on 100%

CXR: Unremarkable

EKG: NSR, Q wave on III, nonspecific ST-T changes on precordial leads


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Laboratory Data

  • Staph aureus sensitivity

    • PCN resistant, oxacillin sensitive

  • TTE:

    • EF 60%,

    • Mitral valve mass consistent with a vegetation on the atrial aspect of the posterior leaflet

    • Apical HK

    • Minimal MR


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Assessment and Plan

  • Acute infective endocarditis complicated with septic emboli to heart and brain

  • Continue medical management

  • Abx changed to IV nafcillin

  • TEE

  • Continue ASA, beta blocker

  • No anticoagulation

  • Continue HD


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HD #2-3

  • TEE:

    • Multiple vegetations on ant/post mitral leaflets on atrial side

    • Largest one 1.2 cm

    • No abscess, cavity or fistula

    • MV prolapse with trivial MR

  • Clinically improving

  • Transfer to floor


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HD #4-10

  • Cyanotic R fingers

    • Doppler: Likely ulnar artery/palmar arch occlusion

    • Septic emboli most likely

    • Observation without any intervention

  • SOB with bibasilar crackles ½ up

    • Cor: 3/6 holosystolic murmur at apex

    • CXR: Pulmonary edema, small B pleural effusions

    • NTG drip

  • Repeat TTE

    • 2-3+ MR (worse than before)

  • BCx: NGTD


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Surgery for Acute Endocarditis

  • Operative mortality 4%-22% (active NVE)

  • Potential indications include: CHF, perivalvular disease, uncontrolled infection, PVE, two (or one) episode of embolization, certain organisms

    • Pseudomonas, brucella, Coxiella burnetii, fungi

  • CHF strongest indication

    • 56-86% mortality w/o surgery vs. 11-35% with surgery

  • Hemodynamic status is the principal determinant of operative mortality

  • Optimal time for surgery is before hemodynamic instability or perivalvular spread

Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330.

Reinhartz O, et. al. Timing of surgery in patients with acute infective endocarditis. Journal of Cardiovascular Surgery 1996;37:397-400.


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HD #11-14

  • No complaints

  • 150’s/90’s 90s 20 Tmax : 38.5 91% on RA

    • Gen: NAD

    • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur

    • Lung: Bibasilar crackles

    • Ext: No edema

    • Bld Cx: NGTD

  • A/P: Persistent fever with endocarditis

    • Rifampin added

    • TEE (show)


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Transesophageal Echocardiogram


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HD #11-14

  • No complaints

  • 150’s/90’s 90s 20 Tmax 38.5 91% on RA

    • Gen: NAD

    • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur

    • Lung: Bibasilar crackles

    • Ext: No edema

    • Bld Cx: NGTD

  • A/P: Persistent fever with endocarditis

    • Rifampin added

    • TEE(show)

  • CT surgery consult  Proceed with surgery


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HD #15-23

  • Operation

    • MV replacement (St. Jude)

    • Primary repair of posterior annular abscess

  • Transfer to CT ICU

    • Intubated, on pressor (milrinone)

  • Post Op TTE: Unremarkable

  • Clinically improving

    • Extubated on HD #17

    • Heparin, coumadin started

    • Transfer to 4E


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HD #24

  • Fever (T 39.8)

    • Repeat Bld Cx sent

  • Micro data

    • MV Cx: No growth

    • MV abscess Cx: Few Candida parapsilosis

  • ID consult

    • Polymicrobial endocarditis?, secondary seeding of vegetation by one of the organisms?, coincidental Staph aureus bactermia?

  • Start fluconazole


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Microbiologic Features of Native/Prosthetic Valve Endocarditis -ages 16 to 60-

Pathogen NVE PVE*

Approx. % of cases

Strep 45-65 1

Staph.aureus 30-40 20-24

Coag-neg staph 4-8 30-35

Gram-negatives 4-10 10-15

Fungi 1-3 5-10

Polymicrobial 1-2 2-4

* Early, < 60 days after procedure

Adapted from Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330.


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HD #25

  • Cross covering surgical housestaff called for fever (T 38.7), tachypnea (R 30-40)

    • Stat labs(CBC, lytes): Unremarkable

    • Blood cultures sent

  • Two hours later, pt in asystole

    • Epinephrine given, intubated

    • Palpable pulse with BP 160/80

    • EKG: Complete heart block

  • Transfer to ICU


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HD #25

  • Assessment

    • Progression of fungal endocarditis involving conduction system most likely

  • Temporary transvenous pacing attempted but unsuccessful

  • Micro data from 27hrs prior

    • BCx: Budding yeast and yeast with pseudohyphae


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HD #25

  • CT surgery

    • Very poor prognosis

    • Not a candidate for reoperation

  • Pt in complete heart block

  • Family Meeting

    • Comfort measures only

  • Pt extubated

  • 6 hrs later, pt died peacefully

  • BCx: Candida albicans

  • No post-mortem examination


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TheNew England Journal of Medicine

February 14, 2002

USE OF A STAPHLOCOCCUS AUREUS CONJUGATE VACCINE IN PATIENTS RECEIVING HEMODIALYSIS

11

26

P = 0.02


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